I/We would like to help individuals, families and communities to be
healthy and drug-free.
Name
Address
City
State Zip
Daytime Phone
E-mail
Contribution:
$25
$50
$100
$500
$1,000
$5,000
Other
Check
is enclosed
Please bill me:Monthly
Quarterly
Other
I would like my
gift to be anonymous
My company matches
donation amounts (Please include your company's form with your donation)
Direct my donation
where it is needed most
I would like to
direct my donation to:
Benton County
Clinton County
(New Directions)
Outpatient
Treatment
Hightower Place
Prevention
Services
King House
Jackson County
Outpatient
Treatment
Outpatient
Treatment
Prevention
Services
Prevention
Services
Jones
Linn
Outpatient
Treatment
Adult Residential
Prevention
Services
Heart of Iowa
Youth Residential
Other (please specify)
Outpatient
Treatment
Christian-Based
Multicultural
Prevention
Services
Thank you for your support!
Please
print this form for your records and
mail a hard copy to ASAC, 3601 16th Avenue SW, Cedar Rapids, IA 52404
or save and e-mail to info@asac.us
Area Substance Abuse Council
3601 16th Avenue SW
Cedar Rapids, IA 52404
319-390-4611